Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
Best Pract Res Clin Rheumatol. 2012 Oct;26(5):659-76. doi: 10.1016/j.berh.2012.07.012.
Over the last decade, a number of biologic response modifiers (BRMs) have emerged and transformed rheumatoid arthritis (RA) management. Due to their relatively high costs, economic evaluations have attempted to determine their place in the RA treatment armamentarium. This article reviews three key areas where changes to the treatment paradigm challenges findings of existing economic evaluations.
We performed a literature search of economic evaluations examining BRMs approved for use in North America for RA. Only economic evaluations that examined relevant direct costs and health outcomes were included. Data were extracted and summarised, then stratified by patient population and comparators. Reported incremental cost-effectiveness ratios (ICERs) were compared across studies.
It appears that tumour necrosis factor (TNF) alpha inhibitors are less cost effective compared to disease-modifying anti-rheumatic drugs (DMARDs) for first-line treatment. In addition, it appears that treatment with a TNF alpha inhibitor in patients who were refractory to previous DMARD therapies is more cost effective, compared to switching to another DMARD. Finally, after an inadequate response to a TNF alpha inhibitor, it appears that therapy with rituximab is more cost effective than treatment with another TNF alpha inhibitor or abatacept.
It is important to acknowledge that cost effectiveness depends on which comparators are included in the analyses and the evidence for the comparators. The most typical comparator in the studies was traditional DMARDs, mainly methotrexate. However, as more BRMs come into the market and new clinical evidences emerge on the comparative effectiveness of BRMs, new economic evaluations will need to incorporate this information such that reimbursement decisions can be fully informed regarding relative value.
在过去的十年中，出现了许多生物反应调节剂（BRM），并改变了类风湿关节炎（RA）的治疗模式。由于其相对较高的成本，经济评估试图确定它们在 RA 治疗武器库中的位置。本文综述了三个关键领域，其中治疗模式的变化对现有经济评估的发现提出了挑战。
我们对在北美批准用于 RA 的 BRM 的经济评估进行了文献检索。仅包括检查相关直接成本和健康结果的经济评估。提取和总结数据，然后按患者人群和比较剂分层。比较了研究之间报告的增量成本效益比（ICER）。
似乎与疾病修饰抗风湿药物（DMARD）相比，肿瘤坏死因子（TNF）α抑制剂作为一线治疗药物的成本效益较低。此外，对于先前对 DMARD 治疗耐药的患者，使用 TNFα抑制剂治疗似乎比改用另一种 DMARD 更具成本效益。最后，在 TNFα抑制剂治疗反应不足后，似乎用利妥昔单抗治疗比用另一种 TNFα抑制剂或阿巴西普治疗更具成本效益。
需要认识到成本效益取决于分析中包含的比较剂以及比较剂的证据。研究中最典型的比较剂是传统的 DMARD，主要是甲氨蝶呤。然而，随着越来越多的 BRM 进入市场，以及关于 BRM 比较有效性的新临床证据出现，新的经济评估将需要纳入这些信息，以便在有关相对价值的信息方面做出充分知情的报销决策。
